Improving Respirator Use and Compliance in Healthcare – An Invitation

Posted on by Ronald E. Shaffer, Ph.D. ; Debra Novak, DSN, RN; Jaclyn Krah, MA


Photos courtesy of Kimberly Clark, Moldex, 3M, and Alpha Protec

Poor compliance with respiratory protection requirements and proper use recommendations in healthcare settings remains a vexing problem. Given the many possible methods to improve compliance, and the constraints of limited budgets and resources available for research, we are asking the question: where should NIOSH conduct research to address this issue?

There are many reasons to focus attention on healthcare workplaces.  There are more than 14 million workers in the United States employed in the healthcare field.  Healthcare personnel are sometimes exposed to a variety of potential airborne respiratory hazards (e.g., Mycobacterium tuberculosis, hazardous chemicals, influenza etc.).  In some of these situations the patient is the source of the exposure, but still requires medical care. Not surprisingly, some studies have found that compared to non-healthcare settings, healthcare personnel could be at a higher risk of exposure to infectious respiratory diseases.  Preferred methods of reducing exposure (elimination, substitution, administrative, and engineering controls) are often not possible or practical to implement, especially during an emerging infectious disease outbreak or pandemic. 

During these events, respirators are often the only option that can be implemented widely, quickly, and seamlessly in the healthcare setting.  Respiratory protection is often recommended for use until the transmission characteristics of the pathogen are understood and vaccines are available.  Many organizations stockpile respirators as part of their emergency response plans.

Like many other public health or occupational safety and health interventions (e.g., the use of seat belts, hand hygiene, vaccines, personal flotation devices, etc.), respiratory protection requires the user to comply with various state or federal requirements and recommended best practices to receive the full benefits of the intervention.  Studies have shown that failure to implement all aspects of a respiratory protection program can result in inhalation of higher than anticipated airborne hazards. A respiratory protection program has many recommended components including initial and annual fit testing and training on proper use practices. Examples of proper use procedures may include using the recommended sequence of taking off gloves, gowns, and respirators; correct technique for putting on a respirator; and wearing the respirator during all periods of exposure.

The best practice for ensuring respirator compliance among healthcare professionals during a pandemic or outbreak is to demonstrate compliance day to day.  However, observational studies and surveys of healthcare professionals demonstrate that users often put on or take off their respirators incorrectly or, even worse, fail to use them at all. The reasons for poor compliance are complex and multifaceted, but have been linked to poor safety culture, workload issues, time constraints, risk perception, concerns that the equipment is not effective, lack of understanding of proper use, availability, interference with patient care, communication difficulties, and discomfort (e.g., heat, sweating, facial pressure, breathing resistance).

We value your input as we move forward with our research agenda.  If you would like to become involved in creating solutions to address selection, care, and proper use of respiratory protective devices in healthcare, then please consider attending our 2013 NIOSH Personal Protective Technology (PPT) Program Healthcare Stakeholder Meeting on June 18, 2013. Agenda, abstracts, and registration information for the meeting can be found at the following link:

This meeting will take place in Atlanta, Georgia as well as virtually at multiple CDC facilities. If you can’t make it to the meeting in person please consider providing your ideas, thoughts, and concerns in the comments section below.  Thank you in advance for your assistance steering this important research agenda.

Ronald E. Shaffer, Ph.D.; Debra Novak, DSN, RN; Jaclyn Krah, MA


Dr. Shaffer is a Senior Scientist in the Office of the Director of NIOSH’s National Personal Protective Technology Laboratory

Dr. Novak is currently a Senior Service Fellow at NIOSH’s National Personal Protective Technology Laboratory

Ms. Krah is a Health Communication Specialist in the NIOSH National Personal Protective Technology Laboratory. 


Posted on by Ronald E. Shaffer, Ph.D. ; Debra Novak, DSN, RN; Jaclyn Krah, MA

8 comments on “Improving Respirator Use and Compliance in Healthcare – An Invitation”

Comments listed below are posted by individuals not associated with CDC, unless otherwise stated. These comments do not represent the official views of CDC, and CDC does not guarantee that any information posted by individuals on this site is correct, and disclaims any liability for any loss or damage resulting from reliance on any such information. Read more about our comment policy ».

    Dear sir
    I highly appreciate with this but the things is not at all possible in certain area of this world, I do not wanted to mentioned the name,, but I could only say that, here not at all care being taken regarding the gears you talked about, this is only possible in developing countries like yours,,,we medicos and public still need better awareness.

    1) A good start would be for NIOSH/NPPTL to make a definitive statement that
    surgical masks are NOT PPE.

    2) SHEA, IDSA, and APIC should not be advocating for surgical masks (e.g
    their common letter re first responders to H1N1; 2009)

    3) The CSA(canadian Standards Association Z94.4 Guideline) has an excellent
    criteria for respirator selection based on “control banding”

    4) For credibility and reliability, respirator selection must be done by either
    Occupational Hygienists or accredited Biosafety Officers

    5) NIOSH/NPPTL should resurrect the TIL(Total Inward Leakage) criteria…

    my opinion is that medical science is growing faster from any thing and with time one day iam expecting when every thing will be done from a machine like. respiration will also done by machine so heart importance will remain less. every one will share machine on regular basis and will save people who need if they feel difficulty during taking respiration.

    Best of luck to Medical science.

    can a Safety officer always do the respireaor selection???
    Is control banding is useful for us????

    As a 23 year vet in the healthcare industry, I am very glad to see this important topic covered in such a thoughtful manner. Thank you.

    Dave Allan

    Thanks to NIOSH for continuing to address this issue. However, the focus must be on healthcare employers to establish proper respiratory protection programs and train and support their emplyees in their proper use. Too often these employers don’t have programs, don’t train staff and discourage staff from using proper respiratory protection. How many hospital can easily deal with respirator use when a possible TB paitent is identified – few in my experience. So start with the employers and managers.

    The event being held in Atlanta on June 18th is very important for hundreds of thousands of HCP around the world.

    As an occupational health physician, may I suggest the following question be considered: Is exposure to aerosols originating from patients and cadavers during aerosols generating procedures (AGP) mainly a safety issue?

    As you may know, it is largely accepted by health care personnel (HCP) that patients and cadavers body fluids should always be considered “a priori potentially contaminated”. In health care setting, routine practices dictate that the skin and mucous membranes of the HCW should avoid being exposed to biological fluids. However, the recommendations of European, American, Canadian and Quebec public health organizations differ in terms of occupational biohazards management when the infectious status of the patient or the cadaver is unknown. During aerosol-generating procedures (AGP) such as bronchoscopy, autopsy and embalming, where the risk of tuberculosis (TB) transmission has been well documented (clusters),« aerosolization» of these body fluids does not require the full deployment of the hierarchy of prevention measures ( This includes as recommended by the Canadian Standard Association (CSA) standard “CSA Z94.4-2011, to systematically wear as a minimum an adjusted particulate Filtering Face Piece Respirators, N95 actually. However, it is largely accepted that surgical masks do not prevent inhalation of respirable bioaerosols, it is well documented for TB in particular that the HCP exposure is recognized most of the time after the fact and also documented that TB is among potentially severe diseases that patients can be unknown carriers.

    Should risk management be proactive instead of reactive?

    Are workers, employers and society benefiting to let HCP inhale aerosols originating from “a priori contaminated body fluids” systematically produced in the breathing zone of workers involved in AGP?

    As stated by Peterson et al.’s abstract, « HCWs are … unclear about when to use respiratory protection, what type should be used, and how to properly donn and doff respirators».

    Is it possible that ambiguous recommendations from organizations such as CDC contribute to this confusion? You must already know that other public health organizations refer to them. In my opinion, the CDC’s recommendations are not clear enough and can be interpreted according to everyone’s belief and values. For example, in its Guidelines for Safe Work Practices in Human and Animal Medical Diagnostic Laboratories – Recommendations of a CDC-convened, Biosafety Blue Ribbon Panel. MMWR 2012;61(Suppl.):103p. [], it should have been, in my opinion, clearly stated that for autopsy, embalming and bronchoscopy, everyone in the laboratory should wear minimally a well adjusted FFR N95 (with sufficient air changes per hour and organizational preventive measures such as work procedures, etc. etc.) because inhalation of “a priori potentially contaminated” body fluid should be systematically prevented as well instead to recommend a vague risk-analysis. According to reasons mentioned above, the risk analysis is already done for AGP such as bronchoscopy, autopsy and embalming and the hierarchy of prevention measures should be fully deployed with a N95 respirator in order to prevent inhalation deep into the lungs of someone else’s aerosolized body fluids.

    May I suggest that CDC states that inhalation of body fluid of someone else or a cadaver should always be avoided? The problem raised by Peterson would be much simpler to solve because CDC’s recommendations will have a domino effect.

    Workers in other fields have to wear respiratory protection when necessary. There is no need to wait for an asbestos case to try to prevent asbestos related diseases. The problem for HCP is that it is not clear enough when it is necessary. A public health statement that “a priori potentially contaminated” body fluid should not be inhaled would be clearer for the workers and their managers.

    It is not said or written but is it possible that public health authorities worry about costs related to respiratory protection? The answer to this important question would help appreciate quantitatively that even only post exposure prophylaxis for tuberculosis, a prototype of disease, is very costly when taking into account unprevented secondary cases, medicine side effects, epidemiological inquiry, etc. etc.

    Proactive risk management is far better on ethical, social, legal and medical ground.

    I hope this is helpful for your work.
    I hope to have opportunities to contribute to your very important work.

    Luc Bherer MD
    Medical advisor
    Public Health department
    Quebec City, Canada

    Dr. Bherer

    Our earlier comments in 2013 are again topical in light of the recent Ebola
    situation, and the proven unequivocal need for effective respiratory protection.
    I think that NPPTL should again consider TIL criteria for FFPR approval.

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